Health
Heart failure is best defined as an inability of the heart to pump blood forward into the body at a rate that meets the oxygen demands of the body’s tissues. Heart failure produces a constellation of signs and symptoms, which we will explore in this article. One very common symptom of heart failure is fatigue. When there is an inadequate supply oxygen to your body’s tissues, you become tired or find that you cannot exercise as much as you used to. When the blood is not being pumped forward into the body, the lungs can become congested with blood that flows backwards from the heart. As a result, you may feel shortness of breath. The term “congestive heart failure” originates from this symptom of heart failure.
Heart failure is a common cardiac condition, seen most frequently in the elderly population. In the United States alone, there are more than 2 million people afflicted with heart failure. Additionally, about 400,000 new cases of heart failure are diagnosed each year. Despite an overall decrease in deaths due to cardiovascular causes in the United States today, heart failure related death has increased over the past three decades.
What Are the Signs and Symptoms of Heart Failure?
The physical signs of heart failure depend on the duration and severity of the condition, and can be detected by just observing the patient. In general, the following physical signs suggest a diagnosis of heart failure.
Leg swelling
Leg edema, or swelling of the legs, is commonly seen in people with heart failure. The word edema means “swelling” and represents the accumulation of an excessive amount of watery fluid in cells and tissues. It is important to note that leg edema can also be seen in other conditions such as lymphatic obstruction or venous insufficiency (due to poor circulation in the legs of either the lymph or venous blood, respectively), and is not necessarily related to heart failure.
Swollen neck veins, congested lungs
Swelling of the legs is more likely to be caused by heart failure when other signs such as swollen neck veins or congested lungs are also present. Congested lungs are otherwise known as pulmonary edema.
Shortness of breath
One of the earliest symptoms to develop in heart failure is dyspnea (shortness of breath), on exertion. This means that you get winded quicker than you used to with regular, daily activities. In other words, it’s harder for you to catch your breath. You may experience this symptom more acutely when you climb stairs or even walk horizontal distances. Similarly, carrying a bag of groceries or lifting a chair may cause you to huff and puff. Alongside this new and worsening shortness of breath, the patient with heart failure may develop decreased exercise tolerance. You may find that you get quite fatigued with ordinary activities. You may feel more tired than usual or your legs may feel weaker when climbing stairs and doing the chores.
Difficulty breathing in bed
Two other symptoms that are commonly experienced by patients with heart failure are orthopnea and paroxysmal nocturnal dyspnea. Orthopnea is difficulty in breathing when lying flat. I ask patients if they are having difficulty sleeping due to shortness of breath when they lie flat in bed. If a patient requires three or four pillows to breathe more easily at night, then heart failure is a concern. Paroxysmal nocturnal dyspnea is a fancy term to describe the sense of breathlessness that awakens a person from sleep 2 to 3 hours after retiring to bed.
Abdominal discomfort and confusion
In addition to shortness of breath and fatigue, the patient with heart failure may experience abdominal symptoms such as nausea, abdominal swelling or abdominal pain. Moreover, the patient with heart failure may become confused.
If you experience any of these symptoms on a regular basis, it would be a good idea to inform your physician about them. Just as with the physical signs of heart failure, the symptoms of heart failure may represent other conditions that do not involve the heart; therefore, a physician would be helpful in making the proper diagnosis.
The most common causes of heart failure in the United States are coronary artery disease and hypertension (high blood pressure). Hypertension requires the heart muscle to work harder to pump blood forward into the body; in other words, high blood pressure creates a resistance to the forward flow of blood from the heart into the body. Coronary artery disease, otherwise known as ischemic heart disease, occurs when those arteries that supply oxygenated blood to the heart become diseased. These coronary arteries may develop narrowing strictures that do not allow for the easy passage of blood. When this happens, the heart muscle that receives blood from these arteries weakens.
Diseases and conditions that can result in heart failure
When hypertension and coronary artery disease are both excluded as possible causes for heart failure, other diagnoses need to be pursued. The list of other causes for heart failure can be long, as heart failure can be the result of a number of other diseases and conditions. For example, diseases of the endocrine system (glands) such as thyroid disease can sometimes lead to heart failure. Abnormalities of minerals in the body such as calcium or sodium, as well as the ingestion of toxic substances such heroin or cocaine, can result in heart failure. Longstanding and heavy alcohol use can lead to heart failure. The list goes on. Some patients who are treated for cancer with certain chemotherapeutic drugs such as adriamycin or cyclophosphamide may develop heart failure as a side effect of those drugs.
Uncommon causes
Other less common causes for heart failure include infections, especially acute rheumatic fever or viral infections. This is not to imply that all viral infections, like those that cause the common cold, can lead to heart failure. Only some viral infections, such as those caused by the coxsackie virus, can sometimes lead to heart failure. Diseases such as lupus or rheumatoid arthritis are sometimes associated with the development of heart failure as well.
Clearly, while coronary artery disease and hypertension are going to be the most likely causes for heart failure, the proper diagnosis of the less common causes for heart failure requires a careful examination of clinical and laboratory findings.
How Do We Make The Diagnosis Of Heart Failure?
As far as establishing any medical diagnosis, the history and physical examination of the patient is the essential starting point. Any patient who complains of shortness of breath or fatigue, and especially shortness of breath that seems worse at night or when lying down, as well as swelling of the legs or abdomen, merits an investigation of heart failure as a possible cause.
Listening to the heart
I already mentioned those physical signs that help the physician determine whether the patient has heart failure. In addition to examining the patient for swelling of the legs, neck veins or abdomen, and listening to the lungs for signs of congestion, the physician can often gather much information from listening to the heart itself. A patient with heart failure often has an enlarged heart. The muscle pumping chambers of the heart, either the right or left ventricle or both, are dilated. When the heart is enlarged, an extra heart sound is often heard. Moreover, the apical impulse, or point where you can actually feel the pulsation of the pumping heart, is shifted away from the center of the chest and towards the left side of the body.
X-ray, electrocardiogram, and echocardiogram
Some tests that are useful in establishing a diagnosis of heart failure include the chest radiograph (x-ray), electrocardiogram and echocardiogram. An echocardiogram is simply an ultrasound (imaging tool that uses ultrasound waves to create a picture) of the heart that allows close examination of the overall muscle function of the heart as well as the function of the heart valves. With regard to the echocardiogram, you may be asked to undergo an ultrasound of the heart both before and immediately after exercising on a treadmill. This is called a stress echocardiography test; and, it is extremely useful in assessing how your heart functions both at rest and during exercise. All of these tests not only help identify an enlarged heart, but may also point to the cause of the heart failure.
Blood tests
You will also have your blood drawn and analyzed for anemia and thyroid function.
How Do We Classify The Stages Of Heart Failure?
The severity of heart failure is classified according to guidelines outlined by the New York Heart Association. This classification system is universal, and is widely used across the United States and a number of other countries, to help physicians better define just how physically limited a patient is by his or her heart failure.
The New York Heart Association (NYHA) functional classification of heart failure divides this cardiac condition into four categories:
Class I is reserved for those patients who have no limitation of physical activity. In other words, Class I patients experience no shortness of breath or fatigue with ordinary physical activity.
Class II patients, on the other hand, experience a slight limitation of activity; they have fatigue and shortness of breath with ordinary physical activity but are comfortable at rest.
Class III patients are markedly limited in activity. They can experience fatigue and shortness of breath with less than ordinary activity. An example of Class III limited activity is shortness of breath when climbing stairs very slowly, one by one. It is important to note that Class III patients are also comfortable at rest.
Class IV indicates the most severe stage of heart failure. In this class, the symptoms of shortness of breath or fatigue are present even when the patient is at rest, and only exacerbated with any kind of physical exertion.
Heart failure remains a major public health concern with an estimated 2 million Americans affected by the clinical syndrome. This syndrome essentially consists of several components. Shortness of breath with exertion is often the earliest sign of clinical heart failure, but decreased exercise capacity, fatigue, abdominal and/or leg swelling, and confusion may also signal the onset or progression of a disease process that inhibits the heart from pumping blood forward into the body. All patients who present with heart failure should undergo an evaluation to determine the type of heart dysfunction that is causing the symptoms of heart failure. The initial diagnostic evaluation should also include a physical examination and tests such as echocardiography (ultrasound) that will guide the treatment of heart failure.
